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3 4 



EXAMINATION OF THE URINE, 



/ BY 

GEOI; B. FOWLER, M.D., 

EXAMINER IN PHYSIOLOGY, COLLEGE OP PHYSICIANS AND SURGEONS, 
YORK, FELLOW OP THE NEW- YORK ACADEMY OP MEDICINE, 
I, MEMBER N. Y. COUNTY MEDICAL SOCIETY, ETC. 



New- York : 

D. APPLETON & COMPANY, 

549 and 551 Broadway. 

1874, 









46975 




+± V 



PREFACE. \j> * 



This book is intended simply as a " Guide." It lias been 
my endeavor to render the subject and the manipulations as 
plain as possible, hoping thereby to enable the reader to 
acquire a thorough knowledge of the common and important 
characters of the urine. 

In teaching the subject. I have become convinced that a 
few words regarding the conditions which produce the vari- 
ous changes in the urine, normal and abnormal, have very 
greatly assisted the student in mastering the subject, by at 
once revealing its practical import. I have, therefore, intro- 
duced here brief outlines of the physiological and patholo- 
gical influences which bear upon the subject. 

The general arrangement of a manual like this is impor- 
tant ; that which I have adopted is as follows : 

Part I. 

1. Characters of Normal Urine. 

2. Effects of Reagents upon Normal Urine. 

Part II. — Characters of Abnormal Urine. 

Part III. — Urinary Deposits. 

1. Those which are Natural Constituents of the 

Urine, either Separately or in Combination. 

2. Those which are Foreign to its Composition 

under any form. 

Part IV. — Accidental Ingre'dients which do not F»rm 
Deposits. 

Part V. — Quantitative Analysis. • • 

Part VI. — Calculi and Gravel. 

April, 1874. 



EXAMINATION OF THE URINE. 



PAET I. 




1. CHARACTERS OF NORMAL URINE. 




Composition. 




Water, 


938.00 


Urea, . . . .... 


30.00 


Creatinine, ...... 


1.50 


Creatine, 


1.25 


Urate of Soda, j 




" " Potassa, I 


1.80 


u u Ammonia, ) 




Coloring Matter and Mucus, . 


.30 


Biphosphate of Soda, 






Phosphate of Soda, 






" " Potassa, 


- 


12.45 


" "Magnesia, 




x 


" " Lime, 






Chlorides of Sodium and Potassium, . 


7.80 


Sulphates of Soda and I 


\>tassa, 


6.90 



1000.00 

Odor. — The odor of normal urine has been de- 
scribed as resembling that of violets. It is subject to 
many changes, however, depending upon articles of 



6 EXAMINATION OF THE URINE. 

food, and some medicines impart to it a peculiar odor. 
But when this is the case, it is best considered under 
the head of abnormal, which see. 

Color. — The tint of healthy urine is liable to 
variation, though a yellow amber is about the stand- 
ard color.' The coloring matter of urine is a peculiar 
organic constituent called urosacine. It is present in 
definite proportion, and depends upon the amount of 
water whether its presence in the urine be marked 
by a deep or faint color. Excessive indulgence in 
water, malt liquors and wine, and diminished activity 
of the perspiratory apparatus, will cause an increase 
of the watery element in the urine, and consequently 
more or less dilution, when the urine will assume a 
light color, and may even resemble pure water. The 
converse of the above conditions will produce a 
contrary re suit. 

Transparency. — Normal urine is perfectly clear, 
with the exception of a small collection of mucus 
and epithelium which nearly always collect at the 
bottom of the vessel. 

Reaction. — Healthy urine has an acid reaction, 
which is due not to the presence of any free acid, but 
to an acid salt, the biphosphate of soda. This re- 
action may be decided or faint. But it should not be 
understood that unless the urine is acid it is abnormal. 
Indeed, the reaction may vary within healthy limits, 
between well-marked alkalinity and acidity. 

The causes of this irregularity are found to be in 
the diet. It has been ascertained that a vegetable 
diet will lessen and sometimes cause the disappear- 



EXAMINATION OF THE URINE. 7 

ance of the acidity ; and it has been found that after 
a mixed meal, the urine is distinctly alkaline. This 
reaction continues a little while, when the alkalinity 
becomes less, and finally the acid state is restored. 
The acid reaction thus increases during fasting, and 
reaches its greatest degree of intensity after twelve 
hours of abstinence from food. (Roberts.) 

It is well to note that this variation is not due to 
any diminution in the acid present, but simply to a 
sudden accumulation of alkaline ingredients, the re- 
sult of digestion. For during digestion, all the salts 
of the organic acids, such as tartrates, malates, 
citrates, and lactates are transformed into carbonates, 
and as such appear in the urine. Substances con- 
taining these organic compounds are in daily use, 
either as food or medicine. All the fruits and vege- 
tables offer familiar examples, and mineral waters are 
a common cause of a temporary alkaline urine. 

Specific Gravity. — The specific gravity of normal 
urine varies from 1018 to 1025. These limits may be 
extended in individual cases, and, in fact, depend 
greatly upon the quantity of urine voided. In other 
words, the specific gravity bears an inverse ratio to the 
daily quantity. Should we have an increased flow of 
urine from unusual indulgence in drink, or from the 
action of any diuretic, we would not expect the density 
to equal that where the same amount of solid mate- 
rial was present in a less amount of water. For in 
diuresis, except in a few instances of disease, we merely 
have the water increased, and not the solid constitu- 
ents. And, on the other hand, where the individual 



8 EXAMINATION OF THE URINE. 

lias taken little or no fluid, or has perspired freely, or 
is suffering with diarrhoea, the urine would be what 
we call concentrated — that is, the normal amount of 
solid ingredients, salts, urea, etc., would be there 
dissolved in a small proportion of water. And under 
these circumstances, the specific gravity would be ( 
liiffh — even 1030 would not indicate disease. 

Daily Quantity. — The total quantity of urine 
voided by a healthy individual during twenty-four 
hours is estimated to be from 35 to 50 fluid ounces. 
This is subject to variation, depending upon the 
quantity of fluids drunk, the activity of the perspira- 
tory functions, etc. ; for it is evident that should 
there be a small proportion of fluids taken into the 
system, there will be less secreted by the kidneys, and 
vice versa. And should perspiration prevail to an 
unnatural degree, we should be getting rid of the 
water by another channel, and would not expect to 
find the same volume of urine ; and the same may 
be said of watery discharges from the bowels. ' The 
kidneys act as regulators of the water-supply of the 
blood ; they take from it any excess, and when there 
is an insufficiency, they demand only enough to dis- 
solve the solid substances of the urine, and to facili- 
tate their discharge from the body. 

The estimation of the daily secretion of urine is 
one of the most important points connected with its 
study. It, however, depends greatly upon another 
condition for its significance to the physician — 
namely, specific gravity. 

The most important and abundant solid ingredient 



EXAMINATION OF THE URINE. V 

of the urine, urea, is present in increased quantities 
as a result of muscular exercise and diet ; therefore ' 
remember to consider these facts in instances where 
a greater density than 1024: to 1025 is found. 

These variations in specific gravity, ranging from 
1006 to 1030, can not be [constant, and not excite 
suspicion regarding the integrity of the kidneys, or 
some pathological condition of the economy. To en- 
title them to be considered under the head of normal, 
they must be only temporary and easily referred to 
some such cause as has been mentioned. 

2. EFFECTS OF REAGENTS UPON NORMAL URINE. 

Cold. — Cold has no visible effect upon urine of a 
specific gravity at or below 1020. But in concentrated 
specimens, after cooling, there will be a precipitate, 
more or less colored, which consists of the amorphous 
urates, they being only soluble in warm urine and in 
an excess of water. This precipitate first appears as 
a cloud throughout the whole volume of urine, but 
will gradually collect at the bottom and adhere in 
specks to the sides of the vessel as a fine powder. 

Such a deposit or cloudiness will disappear upon 
again raising the temperature to that of the body. 

Heat. — Normal urine of a decided acid reaction is 
unaffected by the application of heat. But should 
the reaction be faintly acid, neutral, or alkaline, heat 
will cause a cloudiness, due to the precipitation of the 
earthy phosphates, lime and magnesia. 

These two phosphates are insoluble in a neutral or 
alkaline fluid, and are less soluble in warm than in a 



10 EXAMINATION OF THE URINE. 

cold fluid, and therefore will be precipitated by heat 
if the reaction of urine is even slightly acid. 

Acid. — -The addition of an acid to urine has no 
visible effect beyond deepening the color. But if 
nitric acid be added, in the proportion of about one 
third, after several hours minute but distinct dark 
brown crystals will be seen clinging to the sides of the 
test-tube or vessel, and collect at the bottom. These 
are the crystals of uric acid which have resulted from 
a decomposition of the urates by the nitric acid. 

Alkalies. — When urine is rendered alkaline, the 
earthy phosphates of lime and magnesia will be preci- 
pitated. 

The subaeetate of lead and nitrate of baryta preci- 
pitate the alkaline sulphates, which are said to vary in 
certain diseases. But this proportion in the urine is 
itself variable, and is found to depend greatly upon 
the kind of food taken. 

The nitrate of silver precipitates the chlorides. It 
is sometimes expedient to estimate the comparative 
quantity of the chlorides, inasmuch as it is pretty 
well established that they are subject to great fluc- 
tuations in certain forms of disease. In all severe 
inflammations/pneumonia, pleurisy, cholera, etc., the 
chlorides almost disappear from the urine, and the 
nitrate of silver produces little or no effect. But 
when the attack begins to subside, this reagent will 
detect the return of the chlorides. This precipitate 
is a very copious w T hite cloud. 

Subaeetate of lead and nitrate of silver also preci- 
pitate the mucus and coloring matter of urine. 



EXAMINATION OF THE TJEINE. 11 

Urea. — Urea represents the wornout nitrogenous 
elements of the body. It is excreted at tlie rate of 
about 500 grains per day. If, through any derange- 
ment of the functions^ of the kidneys, urea is not 
thrown off by the urine, it accumulates in the circu- 
lation and acts as a poison upon the nervous system, 
inducing what is called uremia. 

A convenient way to ascertain whether urea is pre- 
sent in the urine, in about the normal proportion, is 
as follows : 

Evaporate 5 f of urine over a water-bath to 1 \ ; 
filter away the phosphates and urates which are depo- 
sited, and allow the clear concentrated specimen to 
cool. Now add about 1 3 of nitric acid, and a copi- 
ous formation of crystals of nitrate of urea will re- 
sult, if the urea is present in any thing like the normal 
quantity. Or a few drops of the urine may be placed 
upon a glass slide and a drop of nitric acid added, 
and the whole allowed to evaporate, w T hen the crystals 
will be distinctly seen, and under the microscope will 
appear as delicate six-sided plates, superimposed one 
upon another. 

CHANGES WHICH TAKE PLACE IN TRINE AFTER BEING 
DISCHARGED FROM THE BODY. 

If a specimen of urine be kept for observation, the 
following changes show themselves : 

At first, after a period varying from two days to a 
week, the acidity becomes more marked, the color is 
darker, and crystals of uric acid and oxalate of lime 
make their appearance. Even should the urine be 
faintly alkaline, to commence with, and cloudiness 



12 



EXAMINATION OF THE URINE. 



exist from the precipitation of the earthy phospates, 
it will become acid, and the cloudiness clear up, when 
the process continues as in the other cases. The aci- 
dity increases up to a certain point, and then begins 
to grow less. It may continue two, four, or seven 
days ; and Lehman states, he has observed the acid 
Fi »- L reaction to increase for 

two or three weeks, and 
then not disappear al- 
together until eight 
weeks.* This is the 

ACID FERMENTATION of 

urine (Fig. 1). 

The acidity gradually 
becomes fainter and 
fainter, and at length 
the urine is neutral. 

Acid Fermentation : Uric acid and octa- -^r- i j i 

nedra of oxalate of lime. JN ow, marked changes 

will be noticeable. The urine is cloudy ; it will con- 
tain conf ervoid vegetations and algae ; myriads of 
infusorial animalcules are visible under the micro- 
scope (vibriones). Neutrality gives place very soon 
to alkalinity, which is advertised most emphati- 
cally by a putrescent, ammoniacal odor. The uric 
acid crystals will disappear, and others of the triple 
2>hosphate of ammonia and magnesia are produced. 
These crystals are large prisms, and can be seen 
glistening on the surface of the urine where a layer 

Dark, round 




of brittle fatty matter has formed. 



' Physiol ogicaVChemistry, vol. 2, p. 121. 



EXAMINATION OF THE TJEINE. 13 

crystals of the urate of ammonia may also be seen 
with the microscope. 

This state of things continues* until the decompo- 
sition is complete. Then the ainmoniacal odor will 
no longer be detected, and the urine will have lost 
most of its color. 

This constitutes the Fig - a - 

ALKALINE FERMENTATION 

(Fig. 2). 

The chemistry of 
these two fermentations 
has been differently ex- 
plained ; but that offered 
by Scherer is generally 
accepted as correct. 

He says that the or- 
ganic matters, the color- 

-i Alkaline Fermentation : Crystals of triple 

mg matter and mUCUS, phosphate] and urate of ammonia, 
, , t .• * j. amorphous phosphate of lime. 

act as catalytic bodies, 

and induce the fermentation whereby lactic acid is pro- 
duced. Just how lactic is formed is not well under- 
stood, but it is certain that it makes its appearance in 
urine when allowed to stand, in which it could not 
be detected when fresh. The presence of lactic acid 
then decomposes the urates, whereby uric acid is set 
free and makes its appearance as crystals. At the 
same time, oxalic acid must be produced, for crystals 
of the oxalate of lime show themselves. This oxalate 
of lime is very insoluble, and could not have existed 
in the urine before without detection. Therefore the 
supposition is that oxalic acid is formed and imme- 




14 EXAMINATION OF THE URINE. 

diately unites with the lime already present. So 
much for the acid fermentation. 

Now, urea is decomposable into the carbonate of 
ammonia by contact with a decomposing organic 
substance, and the addition of two equivalents of 
water. Here then we have the conditions of this 
decomposition. The mucus gradually loses its power 
of producing lactic and oxalic acids, and begins itself 
to decompose ; and surrounded by water, the arrange- 
ment for the transformation is complete. It accord- 
ingly takes place, and the first effect of the presence 
of carbonate of ammonia is to neutralize the acid 
reaction, and then to induce the alkaline. Now, of 
course, the earthy phosphates are no longer soluble, 
and render the urine opalescent by this precipita- 
tion ; the uric acid crystals are dissolved ; a scum of 
animal matter intermixed with the amorphus phos- 
phates now forms on the surface, and very soon 
glistens with crystals of a new formation, the triple 
phosphate or ammonio-magnesian phosphate. (It is 
called triple because it consists of two equivalents of 
magnesia and one of ammonia.) 

At the same time, the carbonate of ammonia acts 
upon the phosphate of soda of the urine, and an- 
other double salt, the phosphate of soda and am- 
monia, is formed. 

The crystals of this last compound salt are very 
similar to those of the preceding, and having the 
same history, and being affected alike by different 
substances, need not be studied apart. 

The urea continues to be decomposed, and the car- 
bonate of ammonia to unite and form these several 



EXAMINATION OF THE UKINE 15 

new substances, until there is nothing more for it to 
unite with. Now it escapes as gas, and the odor re- 
minds us of that common to public urinals, where, 
indeed, the same process as just described is going on. 
At length, all the urea is decomposed, and the evolu- 
tion of the ammonia ceases. The other substances 
either remain unchanged or some pass off in the form 
of other gases. 

These are the important facts concerning normal 
urine, and a knowledge of them is indispensable, in 
that if we are not acquainted with them, we certainly 
shall not be prepared to detect and appreciate the 
variations which constantly present themselves, and 
constitute an abnormal condition. 



PART II. 

CHARACTERS OF ABNORMAL URINE. 

Odor. — The odor of urine is frequently affected, 
and is likely to attract the attention of both patient 
and physician, and lead to its examination. Many 
articles taken as food and medicine impart to it an 
odor peculiar to themselves. Such are asparagus, 
onions, turpentine, cnbebs, and copaiba. An am- 
moniacal odor tells the story of decomposition. 

Color. — The color of urine is subject to many 
changes, depending on the degree of concentration, 
where it will be more or less dark ; on dilution, where 
the lighter shades will prevail,. In febrile diseases, 
where we have a partial suppression of urine, the 
secretion is high-colored. In diabetes miletus, a 
disease characterized by an inordinate flow of urine 
of a high specific gravity and the presence of sugar, 
the tint is light ; also in diabetes insipitus, when there 
is a great increase in the amount of urine of low 
specific gravity. Some articles of food and medi- 
cine also affect the color of the urine. Strong coffee 
heightens the color, rhubarb imparts a deep yellow, 
and logwood gives it a reddish hue. Santonine renders 
it an orange red when alkaline ; when acid, a golden 
yellow. Creosote and compounds of tar have been 



EXAMINATION OF THE UUINE. 17 

known to cause the urine to become almost black ; 



and, lastly, blood and bile may be present in such 
quantities as to be readily recognized. 

The presence of bile may be distinguished from 
the effects of rhubarb by the addition of a little 
liquor ammonia, when the deep yellow of the latter 
will be converted into a crimson. 

Transparency. — If a specimen of urine under 
examination is not clear and transparent, it should be 
first ascertained whether there was any turbidity 
when first voided ; for we have seen that perfectly 
healthy urine, when kept for any length of time, 
will undergo changes and a marked opalescence 
exist. And abnormal urine may be at first perfectly 
clear, but on cooling or standing exhibit a cloudiness 
or deposit. It is possible for urine to be abnormal, 
and yet remain free from turbidity or deposit. For 
example, albumen and sugar are perfectly soluble, and 
can not be detected by simple ocular inspection. 

Substances which interfere with the transparency 
of recently discharged urine are, pus, blood, phos- 
phates, urates (if the specimen is cool), chyle, 
spermatozoa, and epithelium,. 

The reader is referred to each of these under the 
head of " Urinary Deposits." 

Reaction. — After wdiat has been said concerning 
the variability in the reaction of normal urine, it is 
sufficient to J add now that when we meet with a 
patient whose urine is habitually or most of the time 
neutral or alkaline, we should regard him as a subject 
for treatment. 



18 EXAMINATION OF THE URINE. 

Remember that the alkalinity may be due to the 
presence of the fixed salts (soda and potassa), or to a 
volatile one (ammonia) ; that the former are derived 
from the blood, and the latter is the result of the 
decomposition of urea. These two conditions can 
easily be distinguished apart by the ammoniacal odor 
which betrays the presence of carbonate of ammonia, 
and the fact that the blue color which it imparts to 
reddened litmus-paper fades away. And also, if the 
reaction be due to carbonate of ammonia, we shall 
find crystals of the triple phosphate under the micro- 
scope. (Fig. 6.) Where either the fixed salts or 
the volatile one is present, of course the urine will 
be turbid from a precipitation of the earthy phos- 
phates. And this precipitation occurring in the 
bladder is likely to give rise to a calculus ; yet it is 
pretty w r ell established that the urine can remain 
alkaline a long time from the carbonates of soda and 
potassa (fixed salts), and a stone not form. It is 
crystalline deposits which we have to fear in this re- 
gard, and therefore, as the presence of carbonate of 
ammonia results in crystalline formations, calculi or 
concretions are apt to be induced by it. Therefore it 
is very important to recognize these two alkaline con- 
ditions, and to know that when the reaction is due to 
one, the cause pre-existed in the blood ; when to the 
other, the cause is the decomposition of nrea some- 
where in the urinary passages. 

Then, too, we may have the urine abnormally acid, 
producing a scalding sensation during micturition. 
Now, we know what the result is when an acid is 
added to the urine outside thebodv : uric acid crystals 



EXAMINATION OF THE UEINE. 19 

will be precipitated. So it is in. the bladder under the 
same conditions. These crystals then accumulate 
and form gravel, some of which is voided by painful 
efforts by the urethra, but others soon grow by union 
and very soon become a calculus, and by their pre- 
sence irritate and inflame the bladder, which then 
throws off a quantity of mucus and epithelium. These 
products of inflammation supplied with the necessary 
conditions for decomposition, warmth and moisture, 
quickly begin to affect the urine as it comes down 
from the kidneys. The result is, the decomposition 
of urea, production of carbonate of ammonia,' and 
growth of the original uric-acid stone by successive 
layers of the earthy phosphates. 

Daily Quantity and Specific Gravity. — We 

have seen, in the case of healthy urine, how closely 
the specific gravity and daily quantity are related, 
and that as one increased, the other decreased ; or, in 
other words, that they bore an inverse ratio to each 
other. In certain diseased conditions, however, both 
are increased and decreased together. The specific 
gravity may be 1030, and [the daily quantity 60 1 . 
Here we would recognize . the fact that there is a 
double waste of both water and solids. And, again, 
the specific gravity may be 1006 to 1012, and the 
quantity not exceed 12 § . In this case, there is a 
suppression of both elements, and from retention of 
the chief solid constituent, :iirea, the most fatal re- 
sults may follow. There is also a disease — diabetes 
insipitus — where the daily quantity of urine is fifty 
and sixty ounces, and the specific gravity much below 



20 EXAMINATION OF THE URINE. 

the normal standard. This state of thing robs the 
system of its proportion of water, occasioning great 
thirst, whereby nature endeavors to counteract the 
drain. 

Here, then, in abnormal urine, the specific gravity 
and the daily quantity are in direct ratio, except in 
diabetes insipitus. When the amount of water is in- 
creased, the solids will he also, and vice versa. 

The specific gravity of urine may be increased by 
accidental ingredients, such as pus, blood, mucus, 
albumen, and sugar. 

Great care is necessary in collecting urine for ex- 
amination. The patient must be made to~pass the 
entire secretion of twenty-four] hours in one clean 
vessel, and from this total quantity a portion must 
be selected for examination, especially as regards the 
specific gravity. 



PAET III. 

1. URINARY DEPOSITS. 

The urine is subject to deposits, or collections of 
solid and semi-solid substances, which, on account of 
their weight, subside when undisturbed. These de- 
posits consist of various materials, some of which are 
normal constituents of the urine, either separately or 
in combination, while others are foreign to its compo- 
sition altogether. 

Therefore, it will be convenient to study urinary 
deposits by dividing them into these two classes. 

To THE FIRST CLASS BELONG URIC ACID, THE URATES, 
THE PHOSPHATES, OXALATE OF LIME, EPITHELIUM, MUCUS, 
AND PIGMENTS. 

Uric Acid. — Uric acid does not exist in a free 
state in the urine, but is there in combination with the 
alkaline bases, soda, potassa, and ammonia. It, how- 
ever, presents itself independent of these, and forms a 
deposit of dark brown crystals. We have seen that 
this occurs during the acid fermentation of urine, 
and that it is due to the development and action of 
lactic acid, which decomposes the urates. We can 
accomplish the same result by adding any strong acid 
to a test-tube containing- urine, and allowing; it to re- 
main quiet for several hours. Then the characteristic 
uric-acid crystals will be seen attached to the sides 
and collected at the bottom. 

The dark brown color which almost invariably dis- 



22 



EXAMINATION OF THE URINE. 




tin<mislies these crystals is derived from the coloring 
matter of the urine, for which they have a great 
affinity. Yet we sometimes see almost colorless and 
pure crystals of uric acid, and these are apt to be 
small square plates or diamonds. 

The formation of crys- 
tals of uric acid may 
take place in the uri- 
nary passages, not only 
as a result of fermen- 
tation, but spontaneous- 
ly, due to an excessive 
acid condition of the 
urine. In either case, 
gravel and calculi are 
likely to result. It is 
therefore very impor- 
tant to know whether a deposit took place previous 
to the discharge or afterward. 

Fig. 4. A deposit of uric acid 

is of a dark brown co- 
lor, or if pure, it is a 
white, glistening pow- 
der, and under the mi- 
croscope presents the 
greatest variety of crys- 
talline forms. In fact, 
so numerous are the 
shapes and arrange- 
ments of these crystals, 
Uric acid. that it is very difficult to 

give any description. Yet when familiar with urinary 
crystals, they are not likely to confuse one. For it 



Uric acid. 




EXAMINATION OF THE URINE. 23 

is only necessary to be able to recognize the otlier crys- 
talline deposits, which vary little or none ; and then 
when a brown crystal of an unusual form is seen, 
it is pretty safe to pronounce it uric acid. The 
most common appearances are represented in Figs. 3 
and 4. 

Tests. — Uric acid is insoluble in water, alcohol, 
and ether. It is soluble in an alkali, especially at a 
high temperature. 

There is a beautiful test for uric acid called the 
murexid test. Place the uric acid in a clean white 
porcelain capsule, and add a drop or two of nitric 
acid ; then evaporate over the flame of a spirit-lamp. 
When the nitric acid has been driven off, there will a 
pink stain show itself, which, on the addition of a 
little liquor ammonia, assumes a beautiful purple 
color. 

Urates. — The urates, of soda, potassa, and ammonia, 
are present in the urine, in solution, but frequently 
are precipitated, and appear as a dense cloud or 
powder, which collects at the bottom of the urine- 
glass, and at the same time dusts the sides over with 
a powdery film. The color of the precipitate may 
vary from a white to a red, according to the concen- 
tration of the urine, these substances having a great 
affinity for the coloring matter. As a class, the urates 
have very much the same qualities. 

They are soluble in an excess of water at a low 
temperature, but at an elevated temperature, and 
that of the body, they will dissolve in a less amount of 
water. It is this reason that, however concentrated 



24 EXAMINATION OF THE URINE. 

the urine may be when voided, it is never turbid with 
the urates. But in a short time, the temperature falls, 
and a cloudiness is visible, followed shortly by a copi- 
ous deposit. 

Knowing, then, that the urates are precipitated 
when the urine is deficient in water, we can under- 
stand how abstinence from drink, profuse perspira- 
tion, a watery discharge from the bowels, or any 
influence which lessens the normal quantity of water 
in the system, or turns it away from the kidneys, will 
have the effect of concentrating the urinary secretion, 
and causing the urates to appear when the urine cools. 

In fevers, the urates are deposited, and are high 
colored. Irregularity in the digestive apparatus is 
likely to be followed by an appearance of these sub- 
stances. In children teething, we often encounter a 
copious white deposit, which is mostly the urate of 
ammonia. 

As to the relative quantity of the three urates in 
the urine, that of soda stands first, and ammonia last. 

This deposit of the urates is almost always amor- 
phous, though sometimes crystals of urate of soda and 
urate of ammonia are seen under the microscope. 
The amorphous granules sometimes arrange them- 
selves in regular forms, resembling very much 
granular casts, but the application of heat w T ill 
quickly clear up any confusion. Crystals of the 
urate of soda are met with in the urine of gouty 
patients mostly, and have the appearances represented 
in Fig. 5 5 — round masses of dark color, with radiating 
lines from the centre, and irregular projections along 
the circumference. 



EXAMINATION OF THE UKIJSTE. 



25 



The crystals of urate of ammonia appear as very 
dark, spherical masses, and as delicate dumb-bells 
(Fig. 5 a). These crys- Fi ^ 5 - 

tals form during the am- 
moniacal decomposition 
of urine, and can be 
seen under that condi- 
tion (Fig. 1). 

Tests. — The amor- 
phous urates are dis- 
solved by an alkali and 
also by an excess of an 
acid, but their presence 
usually indicates an acid 
urine. The application of heat is the most simple 
test. They dissolve at a temperature of 50° Fahr. 
The murexid test for uric acid is applicable to the 
urates also. 




a, Urate of ammonia. 

b, Urate of soda. 



Phosphates. — It is the earthy phosphates of lime 
and magnesia with which we have to deal as precipi- 
tates. 

The earthy phosphates are precipitated in three 
forms : the amorphous phosphate of lime, the stella 
phosphate of lime, and the ammonio-magnesian phos- 
phate, or triple phosphate. 

The amorphous phosphate of lime is the common 
deposit of urine, which is alkaline from the effects of 
a meal from the carbonates, citrates, etc., taken by 
the mouth, and frequently becomes abundant after 
nervous exhaustion, as want of sleep, hard study, etc. 

The stellar phosj?hate of lime is a crystalline form 



20 EXAMINATION OF THE URINE. 

which sometimes appears in urine. Roberts considers 
its presence indicative of some grave disorder, he 
having encountered it in diabetes, cancer, and phthisis.* 
It may, however, appear in urine where much lime 
has been taken as food ; then if the urine is reduced 
to a neutral or alkaline state, the stellar crystals may 
form. These crystals are arranged in radiating stars 
and bundles, and are perfectly colorless. 

The ammonio-magnesian or triple phosphate is a 
crystalline deposit, the result almost always of the 
alkaline fermentation and the decomposition of 
urea. (See " Fermentation of Urine.") This deposit 
very seldom takes place inside the body, and when it 
does, it is the result of paralysis of the bladder, stone, 
or retention of urine from some other cause. Under 
these circumstances, decomposition takes place, and 
the ammonia, which is one of the results, unites with 
the magnesia already present, and the deposit is 
formed. The ammonia normally present in the urine 
is seldom sufficient to constitute this deposit icithout 
the decomposition of urea. 

The earthy phosphates are only soluble in an acid 
fluid. It is the acid salt, biphosphate of soda, which 
holds them in solution in the urine. But we have 
seen that the urine is frequently neutral and alkaline 
(see u Reaction of formal Urine "), and should expect 
to meet with the phosphates in those instances as a pre- 
cipitate. It is true that we do. Even in urine which 
is weakly acid, they will be thrown down when the 
temperature is elevated, for it is a fact to remember 

* Urinary and llenal Diseases. Am. Ed., 1871, p. 108. 



EXAMINATION OF THE URINE. 



27 



Fig. 6. 



that the phosphates are less soluble in hot than in cold 
solutions. 

A deposit of amorphous phosphates has the appear- 
ance of a white powder, but if the triple phosphate 
be present, the crystals will be easily seen and quickly 
recognized by their large 
size and characteristic 
glistening, prismatic 
forms. (Fig. 6.) 

Tests. — The earthy 
phosphates are distin- 
guished by their solubili- 
ty in any acid solution. 
Therefore if an opales- 
cence or precipitate be 
composed of these mat- 
ters, a drop of any acid Triple phosphates. 

will immediately cause it to disappear. 




Oxalate of Lime. — Oxalate of lime is found in 
urine as a result of the acid fermentation, and also in 
perfectly fresh and undecomposed specimens of this 
fluid. Indeed, the formation may take place before 
the urine is discharged. The source of this forma- 
tion is oxalic acid and lime. It is claimed by many 
that oxalic acid is a normal constituent of the urine, 
and that it, like the other ingredients, is subject to 
variation, and when furnished in a little more than 
the usual amount, it unites with the lime, and the 
oxalate of lime is the result. 

It appears as a whitish powder, and never is very 
abundant. 



28 



EXAMINATION OF THE URINE. 



A great deal has been said concerning the clinical 
significance of oxalate'of lime in the urine, under the 
heads of u Oxaluria" and " Oxalic Diathesis." Some 
writers have maintained that oxalic acid normally ex- 
ists in the blood and urine, and others have declared 
the contrary. 

A long train of symptoms were attributable to its 
presence in the urine, such as nervous prostration, 
despondency, loss of sexual power in the male, etc. 
But I believe these theories have all exploded, and 
from the simple fact that oxalate of lime is very often 
found in the urine of persons in blooming health. 
Indeed, about the only clinical value which attaches 
to this deposit is the possibility of the formation of a 
calculus and gravel. And as these concretions are 
very hard and rough, they are dreaded more than any 
other. 

Tests. — This deposit is always crystalline, and the 

microscopic appearance 
is sufficient in every 
respect to distinguish 
them from any thing 
else. There are two 
kinds of crystals: the 



Fig. 7. 




octahedra, which are the 
most common, and the 
dumb-bell. The first 
consist of two pyramids 
placed base to base. 
(Fio;. 7.) Sometimes 
only a single pyramid exists. Crystals of oxalate 
of lime are usually very small and colorless. Oxalate 
of lime is soluble in strong mineral acids. 



Oxalate of lime : Octahedra and dumb 
bells. 



EXAMINATION OF THE URINE. 



29 



Epithelium, — Every specimen of urine contains 
some epithelium, which is augmented in certain dis- 
eases of the kidneys and urinary passages. In the 
healthy state, we find that from the bladder in the 
greatest amount ; and in the female, vaginal epitheli- 
um will be mingled with the urine, if great care is not 
exercised. 

As the genito-urinary apparatus is lined with epi- 
thelium of different forms throughout its extent, it is 
well to know what are the peculiarities which distin- 
guish that of one region from that of another. 

Vaginal epithelium is very common in the urine of 
women, especially when there is any discharge from 
the vagina or uterus. It is easily recognized by its 
large size, thinness, wa- 
vy outline, and disposi- 
tion to fold upon itself. 
(Fig. 8, h.) The female 
urethra contains very 
similar forms, but they 
are somewhat smaller. 

The tirethra is lined 
by epithelium, which 
differs in the spongy 
and prostatic portions. 
From the meatus to the 
prostatic region, the cells are round and oval. About 
the prostate, they are spindle-shaped, caudate, and 
irregular. 

In the Madder, the size is increased, and they are 
often seen still united by their edges. (Fig. 8, a.) 
Those from the ureters possess the same characters, 
only are of smaller size. 




Epithelium : 



b, Vaginal ; 



30 EXAMINATION OF THE UPJNE. 

The pelvis of the kidney contains small round and 
oval cells, of the flat variety, which are a little larger 
than tubular epithelium. 

The epithelium of the 'kidney tubules is a very 
complicated one, but it is sufficient for our purposes to 
know that it is spherical, about twice as large as a 
blood-globule, from which it may be distinguished, 
should any doubt arise, by its nucleus. It usually 
comes away from the kidney adhering to fibrinous 
moulds of the tubes, but may often be seen floating 
free in the urine. (Fig. 8, c.) 

When epithelium is present in abundance, it will 
be accompanied by an increase in the natural amount 
of mucus, and the two substances settle to the bottom 
of the urine-glass, intimately mingled. Under the 
microscope, patches of epithelium-cells will be seen 
held together by the adhesive mucus. 

Epithelium appears in the urine as a result of any 
inflammation or mechanical irritation of the mucous 
membrane of the urinary tract. 

Mucus. — There is always a small amount of mucus 
in healthy urine, especially in the first passed in the 
morning. It is to the presence of mucus, however 
limited in quantity, that the decomposition of urine 
is due. For if the urine be filtered, it may be kept 
for an indefinite time without any change manifesting 
itself.* 

Mucus appears as a deposit at the bottom of the 
glass, or may entangle air-bubbles and float as a fea- 

* Sclierer. 



EXAMINATION OF THE URINE. 31 

thery ball below tlie surface. It appears of the color 
of the urine containing it, but when separated on a 
filter, is perfectly transparent and glairy. All amor- 
phous and crystalline deposits, blood, pus, casts, etc., 
become mingled with it and interfere with its transpa- 
rency, or may mask its presence. 

Excessive secretion of mucus may be the result of 
mechanical irritation, ammoniacal decomposition of 
the urine in the bladder, or chronic inflammation. 
Sometimes there is such an amount of mucus secreted, 
that the whole volume of urine will be rendered semi- 
solid, and will rope like the white of egg. 

Tests. — Mucus is liable to be confounded with pus, 
especially when colored by amorphous deposits. It 
may be distinguished from pus by its ropy and viscid 
nature, and, best of all, by its appearance under the 
microscope, mucus having no corpuscular elements. 

Pigments. — We frequently encounter peculiar 
little bodies under the microscope, possessing indefi- 
nite shapes and appearances, and attracting the atten- 
tion of the observer by their high color, being either 
red, dark brown, or yellow. 

They sometimes resemble epithelium, but show no 
nucleus ; again, they may be an irregular mass, unlike 
any thing we are familiar with. What is their origin 
and significance? This is an unsettled question, and 
has not been much investigated. They are likely to 
occur in any specimen [of urine, but Koberts states 
that in several cases of chronic Bright's disease, he 
has noticed a great increase of them. 

It has been thought that they might be epithelium- 



32 EXAMINATION OF THE URINE. 

scales, stained by the coloring matter of the urine, 
and this coloring matter itself is known to undergo 
changes whereby other colors are produced capable of 
tinting any foreign substance from the atmosphere, 
which is exceedingly liable to get into a specimen. 

One other source, and a common one, of these col- 
ored specks under the microscope, it is important to 
guard against : it is that they may exist in the glass 
slides or covers ; for these articles are polished with 
a red powder, particles of which become imbedded in 
its minute irregularities. Dr. Edward Curtis was the 
first to w r arn microscopists against this source of error. 

II. 

Second class of deposits : those which are foreign 
to the composition of the urine, under any form. 

This class differs from the preceding in that most of 
the deposits have a pathological significance. 

The following are included under this head : Hood, 
casts, pus, oil, chyle, spermatozoa, cystine, keistine, 
confervoid vegetations, and vibriones. 

Blood. — Blood may be mingled with the urine 
from either of the organs through which it has to pass. 
Urine containing blood may or may not give evidence 
of it when first passed. It depends upon the quanti- 
ty of blood present whether there will be any distinc- 
tion as regards color. 

If the quantity is small, we probably will not sus- 
pect its presence until the urine has stood some hours 
in a urine-glass, when a red line or layer will be dis- 
cernible at the bottom. (It must not be confounded 



EXAMINATION OF THE URINE. 33 

witli uric acid, which is of a dark brown color, instead 
of a blood-red.) The deposit consists of the red cor- 
puscles. 

We may have urine stained with blood, and yet con- 
taining no, or very few, corpuscles. Thus the blood 
may be represented in the urine under these two con- 
ditions : hcematuria, where the elements of the blood 
are present under their natural forms ; hcematinuria, 
where the red corpuscles appear to have disintegrated 
or dissolved, and only a few perfect ones can be found. 
It is necessary to consider these apart. 

Hematuria. — Hematuria is that condition where 
red blood corpuscles are present in the urine, and im- 
part to that fluid a more or less marked bloody color. 
It is the result of ruptured blood-vessels. The rup- 
ture may have taken place from direct violence, con- 
gestion, ulcers, abscess, or the presence of a stone. 
When the kidney is the seat of the lesion, the discol- 
oration of the urine will be equally diffused, on ac- 
count of the admixture beginning at the fountain-head, 
so to speak. The urine will have a smoky hue ; and the 
source of the hemorrhage in the kidney is rendered 
still more conclusive by the finding of casts under the 
microscope. When the blood has originated lower 
down, in the bladder or urethra, it has an opportunity 
to coagulate before the current of the urine diffuses it, 
and consequently when voided, small clots will be seen, 
and the volume of urine will be irregularly colored. 

Tests. — A rupture permitting the escape of the blood 
corpuscles will, of course, allow of the passage of al- 
bumen, and consequently we always find this sub- 



34 EXAMINATION OF THE UHINE. 

stance in hematuria. The corpiiscles themselves are 
albuminoid, and were there no free albumen present, 
would respond to the heat and nitric acid tests. (See 
" Albumen.") But the most positive proof of the pres- 
ence of blood is furnished by the appearances of the 
sediment under the microscope. This instrument, 
with a i-inch lens, will reveal the corpuscles. They 
arebi-concave discs, about y^ of an inch in diameter. 
By careful focusing, their form can be distinguished, 
the outline and centre never being equally distinct 
at the same time ; then if a current be excited in the 
drop under the eye, by touching the side of the thin 
glass cover with a bit of blotting-paper, the corpus- 
cles will roll over and over and show their thin edges 
jng.j)^ an( j concave surfaces. 

All these points are il- 
lustrated in Fig. 9, a. 

There are changes, 
however, which blood 
corpuscles u n cl e r g o 
when subjected to un- 
natural influences. In 
the blood serum, they 
maintain their shape 
Blood comnld^r^N^a; b. Swollen and size, but immersed 
&™t£r? tipil; *' Shriveled from lack in a watery solution 
like urine, they immediately begin to absorb wa- 
ter, and very soon have swollen to twice their 
natural size, lost their color and bi-concave character, 
and are now r spherical. "When allowed to dry, they 
shrivel and become so irregular that should one 




EXAMINATION OF TIIE URINE. 35 

not be familiar with the change, lie will not suspect 
their presence. 

KsBmatinuria. — This curious affection is characte- 
rized by a chocolate-colored urine due to the presence 
of hsematine, which has transuded through the blood- 
vessels, and appears independent of the blood corpus- 
cles which are thought to have dissolved. A few cor- 
puscles, however, are usually seen. Dark granular 
and hyaline casts are frequently found, as well as 
amorphous matter and octahedra of oxalate of lime. 

Tests. — Heat will reveal the presence of albumen, 
which must necessarily be present. When the albu- 
men is coagulated, it is stained by the dark coloring 
matter, and the specimen, when allowed to settle, will 
present the appearance of the chocolate-colored coag- 
ulum at the bottom, and the transparent urine above. 

CASTS. 

Casts are moulds of the uriniferous tubules. The 
kidney is largely supplied with capillaries, which form 
a complex network about the tubules, and any con- 
gestion of the organ is very apt to result in an exuda- 
tion from the blood-vessels into these little canals, of 
a peculiar substance, the composition of which is not 
well understood. This substance has the property of 
spontaneous coagulation, and thus adapts itself to the 
shape and size of the tube, and the urine collecting be- 
hind, washes it out, and it appears as a cast of the 
tubule. The pressure which induces this exudation 
is also sufficient to cause a transudation of the liquid 
portion of the blood ; and it results that albuminu- 
ria always exists where casts are formed. 



36 



EXAMINATION OF THE URINE. 



Fig. 10. 



We depend upon the microscope altogether for the 
detection of casts, and considerable* skill is sometimes 
necessary to distinguish between them and certain 
extraneous matters. The most frequent sources of 
confusion in this respect are cotton fibres and feathers. 
Cotton fibres are striated, and are apt to be folded or 

twisted. A particle of 
feather or hair has de- 
finite anatomical char- 
acters, which should be 
too well know^n to allow 
of a mistake. The ap- 
pearances of these acci- 
dental substances are 
shown in Figure 10. 

As a guide, it may 
be said of casts, that 

a, Hairs ; b, Cotton fibres ; c, Starch ., n i 

grains ; d s Air-bubbles ; e, Feathers. they are generally rOUnd- 

ed at one extremity, and their sides are parallel. 
They are not flexible enough to allow of folding or 
twisting, which is so common to cotton fibres. 

Casts are not all of the same diameter. One reason 
for this is, that the tubules themselves vary in size in 
different parts of their course. Another cause de- 
pends upon the fact that in certain affections of the 
kidney, the epithelium lining the tubules is detached 
and voided with the urine. Now, a tubule thus de- 
nuded is larger than it w T as previous to the shedding 
of its lining, and consequently will afterward form a 
larger cast. 

Casts differ as regards appearance. The coagulable 
matter which transudes into the tubules is perfectly 




EXAMINATION OF THE URINE. 37 

transparent and structureless, so far as we have been 
able to ascertain. The theory is, then, that this mate- 
rial when collected in the tubules fills and distends 
them. This distention causes pressure upon the epi- 
thelium lining which adheres to and sinks into them 
to a certain extent. Now, when the cast is washed 
out by the pressure of urine from behind, it pulls 
slightly upon its epithelial attachments, and if the 
cells be detached or detachable, through degeneration, 
they must come along with it. 

Now, it follows, from the above theory, that if the 
kidney is not diseased to such an extent as to allow of 
desquamation of its epithelium, or, on the other hand, 
if the epithelium has been previously shed, leaving 
the tubule bare, the cast will come away and appear 
in the urine unaltered as regards its structure, and 
will appear as a transparent mould of a renal tubule. 
These we call hyaline casts. 

It is not necessary, after the above explanation, to 
say more than that when the epithelium does show 
itself adhering to the cast, we recognize another va- 
riety — namely, epithelium casts. 

And suppose these epithelium cells to have under- 
gone a fatty degeneration, we should then Imve fatty 
casts. Go a little further, and imagine the epithelium 
to have suffered what is known as a granular degene- 
ration, then we should find granular casts. 
% [Besides these varieties, we meet with several others, 
having nothing to do, however, with the] epithelium 
element. These are blood, pits, and r tcaxy casts. 

As it is my purpose to give a few hints respecting 
the practical bearing of the subjects treated of in this 



38 



EXAMINATION OF THE URINE. 



manual, it will be necessary to glance at eacli one of 
these casts separately. 

Hyaline Casts? as tlieir name implies, are struc- 
tureless and transparent. They vary in diameter from 
the width of one blood corpuscle to that of three. 
Their length is not definite. Being transparent, they 
are difficult to find, and on this account are often 
overlooked. 

The mode of formation of these casts has been 
stated above ; and therefore when they are small, it is 
fair to suppose the kidney yet to be comparatively 
sound, and the cause of the symptoms wliicli led to 
the examination of the urine not of long standing. 
At any rate, we meet with small hyaline casts in acute 
Bright's disease. But what does a large hyaline cast 
signify ? It tells the story of a more advanced dis- 
ease, and its transparency is not due to a refusal of 
Fig. 11. the epithelium to come 

off with it, and thereby 
asserting its healthiness ; 
but, on the contrary, its 
very size bears evidence 
of the previous shed- 
ding of the epithelium, 
and of the present nu- 
dity of the tubule 
whence it came. 

A cast of this last va- 

a, Hyaline casts ; b, Epithelium casts, riety may be perfectly 

transparent, or it may be dotted over with a few 

specks of granular matter, and perhaps here and there 

a broken-down epithelium cell. 




EXAMINATION OF THE URINE. 39 

It is evident, that in chronic disease of the kidney, 
both small and large hyaline casts will be found in 
the urine, because the organ is not equally diseased in 
all its parts. (Fig. 11, a.) 

Epithelium Casts. — We have seen that the effu- 
sion of fibrinous material into the uriniferous tubules 
undergoes spontaneous coagulation, and is afterward 
washed out by the urine which collects behind it ; and 
that if the epithelium lining the tubules be detached 
or detachable, it will adhere to the mould, and be af- 
terward found in that situation in the urine. 

The cells may be scattered upon the surface of the 
cast or may present a regular arrangement, the same 
which existed while they yet occupied their normal 
place in the kidney. At the same time, there will be 
found free epithelium in the urine. 

Epithelium casts are found in the urine of persons 
convalescing from scarlet fever, and in acute Bright's 
disease. In pneumonia and severe inflammatory dis- 
eases, they are the prevailing variety of cast. (Fig. 

1M-) M 

Fatty Casts are epithelium casts in which the epi- 
thelium has undergone a fatty degeneration. The 
cells appear to have beeu filled with fat and to have 
burst, discharging their oily contents into the tubules, 
where they have adhered to the fibrinous effusion. 
The cast will be more or less covered with these mi- 
nute oil-drops and epithelial cells, which are also full of 
oil or fat. At the same time, fatty cells and free fat 
will be seen floating in the urine. (Fig. 12, a.) jj 



40 



EXAMINATION OF THE URINE. 



Casts of tliis description are found in chronic affec- 
tions of tlie kidney, and their presence in the urine is 
a very grave sign. 

Granular Casts represent the epithelial element in 
a state of granular degeneration. What this granular 
material is, is not very well understood, though sup- 
posed to be fat in a state of fine subdivision. The 
cell may have entirely disappeared or may remain, 
filled with these granules. These casts, appearing in 
abundance, are indicative of serious changes in the 
kidneys, and their presence determines an unfavorable 
prognosis. Fig. 12, £, Fig . i 2 . 

illustrates the granular 
cast. It will be noticed 
that they are dark, and 
have ragged extremi- 
ties. 




Blood Casts. — If 

there is a hemorrhage in 
the kidney when the 
conditions are present 
which induce the for- 
mation Of CastS,« the «, Fatty casts ;&, Granular casts. 

blood-globules will attach themselves to the mould, 
sometimes very regularly, and form what is called a 
blood cast. At the same time, they will be present in 
a free state in the urine. 

Blood casts are common in scarlet fever and any 
form of acute Bright's disease. They do not gene- 
rally present themselves for any length of time, being 



EXAMINATION OF THE TJEINE. 41 

the result of a hemorrhage which is not apt to con- 
tinue. 

Pus Casts. — These are rare. They are met with 
where the kidney is the seat of abscess. Yet cases 
where abscess was found at post-mortem examina- 
tions, and furnished no pus casts during life, are re- 
corded. "When present, they have the appearance of 
pus corpuscles adhering to the fibrinous cast. The 
urine will at the same time contain more or less pure 
pus. To prevent confounding pus corpuscles and 
epithelium, it is well to note that they are smaller, 
and the addition of acetic acid will render the cell- 
wall of the pus corpuscle transparent, and reveal a 
distinct granular nucleus. 

Amyloid or Waxy Casts are the large, transpa- 
rent, and waxy-looking objects which are occasionally 
seen, and are thought by some to denote a correspond- 
ing condition of the kidney. But nothing definite is 
yet known concerning them. They sometimes present 
a few transverse markings and fissures, as though they 
were very brittle and had been broken. 

This completes the list of casts, and it may be use- 
ful to sum up their clinical significance. 

The appearance of a few small hyaline casts may 
be, and probably is, the result of a congestion in the 
kidney of recent origin. 

Epithelial and hyaline casts are very frequently 
found in the urine of patients recovering from scarlet 
fever, pneumonia, bronchitis, and congestive diseases 
generally. 



42 EXAMINATION OF THE URINE. 

Fatty, granular, and waxy casts have a grave signi- 
ficance ; yet the appearance of one or two of them 
should not induce us to pronounce too certainly the 
fatal termination of the case. 

It is the continuance of a prevailing kind of cast 
which is most to he relied tcpon in the way of diagno- 
sis and prognosis. 

Casts are liable to disintegrate, and may become so 
changed as to escape detection if allowed to remain 
in decomposing urine. Therefore it is important to 
look for them before decomposition begins. The 
lightest cast will have fallen to the bottom of the 
urine-glass in ten or twelve hours. Then gently pour 
away all the urine except about two drachms, and from 
this, with the aid of a glass tube, take up, from the 
bottom, a drop or two for microscopic examination. 
(See last page for detailed directions for microscopic 
manipulations.) 

Pus. — There are various causes giving rise to pus 
in the urine. Cystitis, pyelitis, gonorrhoea — in fact, an 
abscess or ulceration comumnicating with the urinary 
tract at any point. In women, purulent discharges 
from the vagina are likely to confuse us as to the ori- 
gin of the pus. 

Urine containing pus is turbid when voided, and, on 
standing, deposits a whitish cloud of a ropy consisten- 
cy, which distinguishes it from an inorganic deposit. 

Tests, — Pus consists of a fluid and a corpuscular 
element. The fluid is albuminous, and will be acted 
on accordingly by heat and nitric acid, although puru- 
lent urine never gives a marked coagulum ; and this 



EXAMINATION OF THE URINE. 



43 



fact serves as a good test, the turbidity not disappear- 
ing with heat and nitric acid, and at the same time 
scarcely becoming more marked. 

Liquor potassa causes a semi-solid, gelatinous pre- 
cipitate. 

The microscope will reveal the pus corpuscles, and 
this is conclusive evidence. Pus corpuscles are a lit- 
tle larger than the blood corpuscles, colorless and 
spheroidal. They are made up of cell-wall, granular 
contents, and nuclei. By the addition of a drop of 
acetic acid, the cell-wall 
is rendered transpa- 
rent, and the nucleus is 
brought sharply into 
view. (Fig. 13.) . 

Oil. — It has been as- 
serted that oil is a con- 
stituent of normal urine 
in very small propor- 
tion, and only detected 
after a careful analysis. 
It, however, sometimes 
makes its appearance in quantities sufficient not only 
to be recognized under the microscope, but visible to 
the unassisted eye. 

It may present itself either as distinct oil-drops, as 
granules, or as a very fine emulsion, each particle of 
which appears as a mere point under the microscope 
(this latter condition we have in chylous urine). If 
either of these forms of fat are in the urine, we shall 
have a layer of it on the surface when allowed to rest. 
In the case of granular fat, the layer will appear 




a. Pus corpuscles ; &, 
acid. 



Effect of acetic 



44 EXAMINATION OF THE URINE. 

creamy ; where the globules are of any size, a yellow, 
oily layer will be seen. 

Oil globules were detected in the urine of a man 
who was taking cod-liver oil by Roberts. Fatty de- 
generation of the kidneys is accompanied by oil in 
the urine. Much speculation has been indulged in 
concerning the source of oil where there is no recog- 
nizable affection of any organ. It is known that 
during digestion, the blood is loaded with chyle, and 
may, under circumstances not understood, permit it 
to escape into the urine. (See " Chylous Urine.") 

A frequent source of oil-drops in the urine is the 
vessel in which it is collected, or the bottle in which 
it is brought to the physician, and, in many instances, 
the passage of catheters and sounds, which are always 
oiled before introducing. 

Tests. — Oil is soluble in ether. But if it be in 
small quantity, it often becomes necessary to first 
extract it with ether, and afterward evaporate almost 
to dryness before any traces of it can be seen. 

Under the microscope, oil-drops are distinguished 
by their perfectly circular outline, difference in size, 
and solubility in ether. As seen in urine, the glo- 
bules are never very large, and might be mistaken for 
blood corpuscles. But their sharp-cut, bright outline, 
absence of color, and peculiar properties mentioned 
above, can scarcely fail to identify them. 

Chylous Urine. — Chylous urine has ever been one 
of the most interesting and at the same time puzzling 
conditions with which we have to deal. In appearance, 
it is milky, and on standing collects in a creamy layer 



EXAMINATION OF THE UHINE. 45 

on the surface. There is always more or less blood, 
fibrine, and albumen present. Sometimes it coagu- 
lates spontaneously when passed, and very closely 
resembles blanc mange. Cases are related where it 
coagulated in the bladder and completely blocked up 
the urethra, from which it was extracted in long 
flakes. It is a rare affection, and but few cases are 
reported. Writers disagree widely concerning its 
pathology and symptoms ; but without going over the 
history at length, the following are the main points 
regarding this peculiar disease : 

It is most common in warm climates; makes its 
appearance suddenly, and as suddenly ceases, to re- 
appear again after months or even years. Sometimes 
it coagulates spontaneously, like lymph, and again 
does not undergo this change. Themilkiness is more 
marked after meals. The older authors considered 
the kidneys and the assimilative functions of the 
system to be at fault and diseased. But casts have 
been searched for in vain, and several post-mortem 
examinations of individuals who were affected with 
this disease have failed to afford evidence of altera- 
tions in any organ. So that now it begins to be 
stated that the chyle and lymph are discharged directly 
into the urinary passages from the lymphatic vessels 
themselves ; and Roberts especially advances this 
opinion, having noticed, in patients voiding chylous 
urine, appearances which indicated disease of the 
lymphatics. 

I had an opportunity recently of examining a 
specimen of chylous urine, the history of which it 
may be well to relate. It occurred in the practice of 



46 EXAMINATION OF THE URINE. 

Professor Alonzo Clark. The patient had resided in 
the South most of his life. About ten weeks before 
he consulted Professor Clark, he had attempted to 
pass his urine five times within an hour. This neces- 
sitated great straining, and he was suddenly alarmed 
by a severe pain and a discharge of blood and milky 
urine. (The pain was located in the prostatic ure- 
thra, and as he had undergone an operation for stone 
a few years before, it and the hemorrhage were refer- 
red to that cause.) This condition came and dis- 
appeared several times until I saw the urine. The 
patient stated that the milky fluid sometimes was per- 
fectly free from any urine. He w T as able to know 
this from the fact that the uriniferous odor was 
entirely absent, and, moreover, the bladder had just 
been emptied only a few minutes before. 

This urine did not coagulate spontaneously. It 
contained blood, and had an alkaline reaction. 

Tests. — Besides the characters above stated, other 
tests are scarcely necessary. Chyle is oil in a state 
of emulsion. 

Under the microscope, the granules appear very 
minute. 

Spermatozoa. — The spermatic elements some- 
times become mingled with the urine in sufficient 
numbers to form a deposit. As a deposit, they re- 
semble mucus and pus, though never so abundant. 
Their presence may be accounted for as a result of 
coition or an involuntary discharge of semen. This 
latter may be continuous and constitute spermator- 
rhoea. With the exception of this last-named condi- 



EXAMINATION OF THE UHINE. 



47 



tion, the presence of spermatozoa in the urine is 
without significance. 

Tests. — The semen is albuminous, and will be ren- 
dered cloudy, to a more or less degree, by heat and 
nitric acid. But the microscope will reveal whether 
the albuminous reaction is due to the presence of 
semen, in that the characteristic filaments or sperma- 
tozoa will be seen. If the specimen be recent, they 
will be in active motion. Spermatozoa are possessed 
of a head and tail-like extremity, the former being 
slightly flattened from Fig. 14. 

before backward. Their 



length is about 



t 

"6" oo 



of 




Spermatozoa; b, Vibriones. 



an inch. (Fig. 14, a.) 

Cystine.— This is a 
substance but rarely met 
with, compared with 
other deposits. Its 
source is not positively 
known, though supposed 
to be the liver. A 
remarkable fact concerning it is its liability to run 
in families. The most important clinical significance 
attached to it is its liability to form a calculus ; 
otherwise cystine may appear in the urine of an indi- 
vidual for years and not depreciate the health. 

Urine containing cystine has usually an oily ap- 
pearance, and deposits a light, rose-colored powder. 
Decomposition takes place very soon, and, according 
to Dr. Bird, the color changes to a green. Cystine 



48 EXAMINATION OF THE URINE. 

contains sulphur, which is decomposed and evolved 
as sulphuretted hydrogen. 

Tests.— Acetic acid will cause a further precipitate 
to take place. It is insoluble in the vegetable acids, 
and is not dissolved by heat. It is soluble in 
ammonia and mineral acids. 

The crystals are six-sided plates, and colorless. If 
a solution of cystine be placed in a shallow dish with 
Fi s- 15 - a little ammonia, evapo- 

ration w T ill cause a de- 
posit of the pure crys- 
tals. (Fig. 15.) 

Keistine. — It was at 

one time thought that 
the urine of pregnant 
women offered peculia- 
rities by which the preg- 
nant state could be diag- 
Cystine * nosed. It was stated 

that there would form upon the surface of such urine 
a layer of cheesy matter unlike any appearance pre- 
sented when the subject was not pregnant. . The 
name keistine (cheesy) was given to this formation. 
The results of observation, however, have been so 
conflicting that the profession, to-day, reject the 
matter, and attribute the phenomenon as one and 
the same thing as the alkaline fermentation, which is 
hastened in pregnancy by the presence of an increas- 
ed amount of animal matter, such as epithelium and 
mucus from the vagina and bladder. 




EXAMINATION OF THE URINE. 49 



VEGETABLE FUNGI. 

There are several microscopic vegetable growths 
which invade the urine. The most important are the 
Penicilium glaucum, or common mould ; the To- 
rula cerevisiw, and Saccharomyces cerevisice, or sugar 
fungus. 

Penicilium Glaucum — This fungus will appear 
in any urine kept any length of time at an elevated 
temperature. In warm weather, it sometimes makes 
its appearance at the end of twenty -four or forty-eight 
hours. 

There may or may not be any very visible deposit ; 
this depends upon the growth of the, fungus. But it is 
often encountered under the microscope, when not 
seen in the urine by the unassisted eye. 

There is a vegetable part, the mycelium, and a 
fructifying part, the Fig. 16. 

spores. The mycelium 
is nothing but an irregu- 
lar ramification and in- 
terlacement of fibres, 
some of which shoot up- 
ward toward the surface 
of the fluid, and on 
reaching it, develop 
upon their extremities 
the spores. And it is 
simply by the arrange- Penicilium glaucum, 

ment of these spores that we are able to distinguish 
most of the different varieties of mould. In the 




50 EXAMINATION OF THE URINE. 

penicilium glaucum, the spores are arranged in 
projecting rows upon the stem. (Fig. 16.) They 
ripen and fall, or are blown away to other quar- 
ters ; but in either case, they immediately begin to 
elongate, and then to branch, until a mycilium of 
new growth is formed. We must see the spores while 
yet on the stem, in order tp judge of the variety of 
the fungus, for they so closely resemble other spores, 
that it would be a difficult matter to recognize them 
when once dislodged and separated. 

Torula Carevisise. — This fungus was formerly 
supposed to be the true sugar-mould, and its growth 
in a solution considered a pretty sure evidence of the 
presence of sugar. 

But it is now known that it will show itself in 
fluids where the most delicate chemical tests fail to 
detect sugar. 

It is very similar in appearance to the penicilium 
just described, but can be distinguished by the arrange- 
ments of its spores, they being arranged in spheres, 
upon the end of the stem. 

Saccharomyces Cerevisise — This is the growth 
which we will find in saccharine solutions, and more 
particularly concerns us, as its presence may deter- 
mine whether a specimen of urine contains sugar in 
those instances where chemical tests are not very 
definite. 

In order to become perfectly familiar with the 
appearances of this fungus, I advise every one to do 
the simple thing of making a solution of a little egg 



EXAMINATION OF THE URINE. 



5L 



albumen, honey, and water, and keep at a temperature 
of about 100° F. for twelve hours, and examine the 
sediment under a microscope. 

We shall discover numerous round or ovoid bodies 
of a brown color. Some will contain distinct nuclei. 
Some will have budded, and appear as two or three 
cells fused together. By careful examination, every 
stage of this growth or budding will be seen, instances 
where the new shoot is just appearing, and again a 
distinct row of full- 
grown cells. (Fig. 17.) 

Vibriones. — These 
are microscopic objects, 
and are almost the low- 
est order of the infuso- 
rial animalcules. They 
appear in decomposing 
animal infusions, and are 
common to urine during 
the alkaline fermenta- 
tion. They are about 
go^o of an inch in length, and are in constant 
motion. (Fig. 14, b.) They are propelled by a spiral 
or corkscrew-like movement. 




Saccharomyces cerivisiae. 



PART IV. 

ACCIDENTAL INGREDIENTS WHICH DO NOT FORM 
DEPOSITS. 

There are certain abnormal substances which are 
frequently present in urine, but are in such perfect 
solution as to afford no evidence of their presence by 
way of a deposit, and may have little or no effect 
upon the natural color (with the exception of bile). 

Such are albumen, sugar, and bile. (I shall not 
consider those matters which, taken by the mouth, as 
food or medicine, subsequently appear in the urine.) 

Albumen. — Albumen frequently constitutes an 
ingredient of the urine. As such, it is derived from 
the blood, and, in fact, is a portion of it. It may be 
the fluid albumen of the blood plasma which has 
exuded through the renal circulation from congestion 
or over-distention of the vessels; or it may be the 
albuminoid corpuscles themselves which have been 
mino-led with the urine as a result of a hemorrhage 
somewhere in the tract. 

Almost all the congestive diseases are accompanied 
by albuminuria, and any interference in the return 
flow of blood from the kidneys for any length of time 
will almost surely be followed by albuminous urine. 
Diseases affording this interference are pneumonia, 
scarlet fever, and inflammatory affections generally. 
The pressure of the pregnant uterus or any tumor 



EXAMINATION OF THE URINE. 53 

upon the renal veins is a common cause of albumen 
in the urine. And most important of all are the 
affections of the kidneys themselves, whereby they 
lose the power of eliminating the urine alone, but 
allow constituents of the blood to escape at the same 
time. We judge of the condition which produces 
albuminuria very much by the presence or absence 
of casts, and by the kind of cast which accompanies 
the condition (see " Casts"), for casts and albumen 
almost always exist together. Urine containing albu- 
men is apt to be of less specific gravity than normal. 
Albuminous urine froths on pouring from one vessel 
to another, and this fact is the first, oftentimes, to 
attract the attention of a patient. 

Tests. — Albumen is precipitated by heat, the 
mineral acids and their salts. But two of these are 
necessary — heat and nitric acid. If heat is to be 
applied, first see that the urine is acid ; if it is not, 
add a drop or two of acetic acid. Now boil, and if a 
precipitate come down, it can be nothing else but 
albumen. On the other hand, if an alkaline urine is 
subjected to boiling, the earthy phosphates are preci- 
pitated and might lead to error. However, a drop 
of any acid added to such a precipitate would quickly 
decide the point. If it be phosphates, the acid will 
dissolve them ; if albumen, it will not. (See " Phos- 
phates.") It is best to have another test tube of 
the same size filled with the unboiled urine for com- 
parison, when any delicacy is necessary. Nitric acid 
is the most delicate test. Incline the test-tube con- 
taining the suspected urine, and allow a drop of ni- 
tric acid to run down the side and gain the bottom. 



54 EXAMINATION OF THE URINE. 

It will appear there as a perfectly clear layer, and if 
albumen be present, a white stratum will be seen just 
above it where the urine conies in contact with it. 

An easy method to estimate the amount of albu- 
men is to coagulate it by heat or nitric acid, and 
allow the coagulum to settle to the bottom of the test- 
tube. The amount compared with the quantity of 
urine present, as J, i, etc., will enable us to detect any 
change from day to clay. 

Sugar. — There is a pathological condition marked 
by the excretion of an enormous quantity of urine of 
high specific gravity — 1030-1060, and containing 
sugar. The disease is diabetes melitus. 

It is an established physiological fact that the liver 
produces sugar entirely independent of any starchy 
or saccharine substances used as food ; but it is by ho 
means established that the liver is the origin of the 
sugar found in the urine. 

The color of diabetic urine is most always light, 
the specific gravity high. Albumen is frequently 
present. 

Tests. — If saccharine urine be boiled with liquor 
potassse, it wall assume a dark brown or molasses 
color. This is known as Moore's Test. It is unreli- 
able in that any urine of high specific gravity will give 
the same result. 

If a little yeast be added to urine containing sugar, 

fermentation will ensue, whereby carbonic acid gas 

and alcohol will be produced. The gas escaping in 

bubbles can be collected and tested. This is a good 

test, but not very convenient. It is rarely resorted to, 



EXAMINATION OF THE URINE. 55 

because we possess another, easier and entirely satis- 
factory, namely : 

Trommer's Test, — This method of determining 
the presence of sugar in a solution is based upon the 
fact that sugar possesses the property of reducing the 
salts of copper in an alkaline solution at the boiling- 
point. 

The usual mode of applying this test is to add two 
or three drops of a solution of sulphate of copper to 
a quantity of the suspected fluid in a test-tube, and then 
pour in an excess of liquor potassse. The whole 
now assumes a deep, transparent blue color. Now boil, 
and if sugar be present, the suboxide of copper will be 
thrown down as a bright yellow precipitate (in some 
cases an orange red). When this change occurs, the 
blue color disappears entirely, and the mixture be- 
comes perfectly opaque. 

Unfortunately, when applied to the urine after the 
above manner, these phenomena do not present them- 
selves. Having added the copper and potassae, there 
will appear the usual transparent blue color. Now 
boil the solution, and almost invariably we fail to see 
any thing like a yellow or red precipitate. Either 
the blue color is entirely destroyed, and a dark, trans- 
parent, molasses color appears, or there is a dirty green 
precipitate. 

Considerable lias been written concerning the in- 
applicability of Trommer's test to the urine, the expla- 
nation being that the organic constituents, urea, color- 
ing matter, etc., interfere with the reduction of the 
suboxide of copper. Directions have therefore been 



56 EXAMINATION OF THE URINE. 

given to get rid of these matters by filtration through 
finely-powdered animal charcoal. 

This process is an efficient, but, as a general rule, 
not a convenient one to the practicing physician. 
Therefore, as a result of some recent investigations on 
the subject, I submit the following hints and rules for 
the application of Trommer's test to the urine as being 
a perfectly simple and reliable method : 

In the first place, it is necessary to have a great 
excess of the test, because if the urine he in too great 
quantity, the precipitate i$ dissolved, and on this fact 
depends my method. 

Judge by the specific gravity of the urine and the 
history of the case whether there is much sugar present. 

If the evidence is in favor of a considerable amount, 
take about ten drops of the urine in a test-tube, and 
add two drops of a solution of sulphate of copper 
(strength, 13-1). If very little sugar is suspected, 
take about ten drops and one drop of copper solution. 
Now, add liquor potassee until the mixture assumes a 
perfectly clear blue color. If the addition of the 
potassse in excess induces a permanent milkiness 
instead of a transparent blue, it is apt to be due to 
too much copper having been added. Now, subject 
the solution to boiling, and 

If no sugar bepresent, a flocculent green precipitate 
comes down, leaving the liquid colorless. 

If sugar be present, an orange red or yellow pre- 
cipitate will appear. 

(When the sugar is in excess, the color of the pre- 
cipitate is yellow. When the copper is in about 



EXAMINATION OF THE URINE. 57 

proper proportion, the color of the precipitate is orange 
or red.) 

When the copper is in excess, the precipitate is 
greenish yellow, but soon changes to orange. If no 
change occur immediately, set the test-tube aside and 
wait. 

If a dark, molasses, transparent color manifest 
itself, there is very probably sugar present, but too 
much urine was used, and has dissolved the copper 
precipitate ; therefore take the same quantity of 
urine as before, and add four or five drops of the 
copper solution. 

Do not mistake the flocculi of the phosphates, 
thrown down by the alkaline test fluid, for a precipi- 
tate of the suboxide of copper. This latter is dark 
red or yellow, and soon subsides to the bottom of the 
test-tube, and is seen there as a compact little mass. 

The main points of the foregoing method for the 
application of Trommer's test to the urine are that, 
1st. I have found the urine capable of dissolving the 
copper precipitate. 2d. A certain quantity can only 
dissolve a certain quantity of said precipitate. 3d. 
Therefore take a very little urine to begin with, for 
if ice use much xirine, we have to put in copper enough 
to allow for the dissolving power of that amount of 
urine and some over for the sugar to attack. Now, 
before ice could produce a clear blue color by the 
addition of potash solution, the test-tube would over- 
flow. 

The test with Feeling's Solution (for composition, 
see p. 60) is based upon the same principle as the 
foregoing, and if we have the solution, it is a very 



58 EXAMINATION OF THE URINE. 

easy and reliable test. But it has to be made, and 
when kept for any length of time, is liable to undergo 
changes which unfit it for further use. 

The way to use it is to take a test-tube a quarter full 
and boil it. To this add a drop of the suspected 
urine if much sugar is present ; if little, add ten or 
fifteen drops. 

Here we have the same principle as advised with 
Trommer's test — namely, a small quantity of urine 
and a great excess of the test fluid. 

If any change occurs in the Fehling liquor when 
boiled alone, it is unfit for use. 

Bile. — The coloring matter of the bile is frequently 
excreted with the urine, imparting to it a more or 
less greenish-brown color. 

It occurs in jaundice even before the skin has be- 
come perceptibly colored, and continues a little while 
after the natural color is restored. 

The biliary salts, glykocholate and taurocholate of 
soda, sometimes are present also, and it is frequently 
important to know whether the bile is represented in 
the urine solely by its coloring matter, or whether 
these more important ingredients are there too. 

Tests. — The coloring matter of bile can be detected 
by pouring a little of the urine into a white plate, 
and allowing it to come in contact with a few drops 
of nitric acid. As the two mingle, a play of colors 
will be observed, varying from a violet to a green. 
Any oxidizing agent, tincture of iodine, or the 
atmosphere, will produce a grass-green color. 

To detect the biliary salts,~we must resort to Pet- 



EXAMINATION OF THE URINE. 59 

tenkofer's test, as follows : Make a watery solution of 
the urine, if the color be very marked, and pour about 
3 ii of it into a test-tube. To this add a few drops of 
a solution of cane-sugar (one part to four of water). 
Then very gradually drop in sulphuric acid. The 
mixture becomes heated by the action of the acid, 
but must be kept below 50° F. Vqry soon, if the 
biliary salts are present, and care is taken not to 
agitate the mixture, a red color will appear at the 
bottom of the test-tube. Xow, cease adding the acid. 
The red gradually changes to a crimson, and finally 
a beautiful claret pervades the whole. # 

It is this play of colors which constitutes the most 
characteristic feature of the test. 



PAKT V. 
QUANTITATIVE ANALYSIS. 

SUGAR — UREA, 

There are only two substances of which the medi- 
cal man will be often called upon to estimate the 
quantity in the urine — they are sugar and urea. 

Sugar. — The quantitative analysis of sugar in the 
urine is performed with Fehling's solution, which has 
the following composition : 

Sulphate of copper, . . 90 £ grains. 
Neutral tartrate of potash, . 364 
Solution of caustic soda (sp. gr. 1.12), 4 fluid 
ounces. 
Add water to make exactly six fluid ounces. 

The following apparatus is necessary : 200 grain 
measure ; burette graduated to grains ; 8 1 flask ; spi- 
rit-lamp and stand upon which to place the flask to 
boil its contents. 

Fehling's solution contains a definite amount of 
sulphate of copper in an alkaline solution. The gra- 
duation in the above formula is such that 200 grains 
of the solution correspond, or are decomposed by 1 
grain of sugar ; and when this decomposition has 
taken place, of course the blue color of the sulphate 
of copper is gone. 



EXAMINATION OF THE URINE. 61 

So, proceed as follows: Diabetic urine usually con- 
tains so much sugar that it is best to dilute it in this 
analysis : as much as one in ten, if sugar be very 
abundant ; one in five or pure urine, if in small pro- 
portion. Suppose we wish to dilute it as much as 
one in ten : take 4 J ounces of water and -J- ounce of 
the urine and mix well. Now, measure out 200 grains 
of the copper solution and pour it into the flask. 
This had also better be diluted with twice its bulk of 
water, then set it to boil. Then, if you have a bu- 
rette, fill it up w r ith the diluted urine to the O mark. If 
a burette is not at hand, measure out a certain quan- 
tity, and remember it, for you will wish to know how 
much of the diluted urine has been used. By this 
time, the blue liquid in the flask is boiling. Now, very 
carefully add drop by drop the urine from the burette 
or what you have measured, and watch the result. 
As the saccharine urine comes in contact with the cop- 
per solution, some of the latter is decomposed, and 
appears as a red powder. Let it boil after each addi- 
tion of the urine. 

A time will at length arrive when all the blue color 
will have disappeared, and a red, insoluble powder 
taken its place. 

Cease the whole operation every little while, and 
let this red oxide of copper settle, when it will be 
easier to determine whether any blue color yet remains 
in the supernatent liquid. During the last part of the 
operation, proceed very, carefully, for there is great 
danger of adding too much sugar, and then immedi- 
ately the whole experiment is spoiled. The mixture, 
under these circumstances, will turn suddenly of a 



G2 EXAMINATION OF THE URINE. 

molasses color, the result of the action of a boiling 
alkali upon the sugar. 

Having been cautious then, suppose you have added 
diluted urine until the blue color has entirely dis- 
appeared. Now, then, refer to your burette or mea- 
sured quantity which you poured out to commence 
with. How much of the diluted urine has been used ? 
Say 250 grains. But this is only one tenth urine ; we 
have therefore only used 25.0 grains pure urine. 
These 25.0 grains of the pure urine contain one grain 
of sugar, because it has reduced the copper in 200 
grains of the standard Fehling's solution. Divide 25 
into 100, and we have the percentage of sugar in the 
specimen of urine, or 4 per cent. 

Fehling's solution is liable to undergo spontaneous 
decomposition, as has been before mentioned, and it 
should always be boiled thoroughly before using ; if 
perfect, no change in color is induced by boiling. 

In order to obviate this disadvantage of the decom- 
position of Fehling's solution, Professor Chandler re- 
commends the following method, and to those familiar 
with the French system of weights and measures, it is 
superior to any other : 

Take 34.639 grammes of copper sulphate, and dis- 
solve in 1 litre of water ; 10 cubic centimetres of this 
correspond to .05 grammes of sugar ; 10 c.c. of this 
copper solution, therefore, are placed in a flask and di- 
luted with about four times as much water. Now, put 
in a pinch of tartaric acid (to prevent the precipitation 
of the hydrate of copper when the potash is added). 
Shake the mixture, and then pour in a solution of 
potassic hydrate until the whole assumes a clear blue 



EXAMINATION* OF TriE URINE. 63 

color. Now, proceed exactly as directed in tlie other 
case, except that instead of grains of urine, we mea- 
sure out cubic centimetres. That is, take 2 c.c. of 
urine, if the sugar present be in large proportion, and 
dilute it with 18 c.c. of water. Now, the mixture 
consists of one tenth urine. (This dilution is resorted 
to in order that we may add the sugar more gradually, 
and not overadd it.) 

Suppose, then, we have used 20 c.c. of the diluted 
urine ; but this only contains one tenth, or 2 c.c. of 
pure urine. Therefore : 2 c.c. : .05 grammes of sugar:: 
100 : quantity of sugar = 2.5 per cent. 

The advantage of this method depends upon the 
fact that the copper, tartaric acid, and potash are not 
mixed until we wish to perform the analysis, and 
therefore do not deteriorate by keeping. 

Urea. — The daily quantity of urea excreted fre- 
quently becomes of importance, and various methods 
of estimating it have been advised. None are so 
simple as the one proposed by Dr. Davy, of England.* 
Doubts having arisen as to its accuracy, I undertook a 
series of experiments in order to ascertain if they 
were well founded.f The results of these experiments 
led me to the conclusion that the method was in every 
respect sufficiently accurate for practical purposes, and 
I therefore introduce it here as the one best adapted 
to the physician who wishes to perform the analysis 
himself. 

The analysis depends upon the decomposition 

* Philosophical Mag. 1854. \ New-York Med. Jour., Sept. 1872. 



G4 EXAMINATION OF THE URINE. 

which ensues when urea is brought in contact with 
the hypochlorite of soda, potash, or lime. 

Nitrogen gas is evolved, and being collected and 
measured, the amount of urea originally present is 
estimated. The following are Dr. Davy's directions: 

U A strong glass tube, about twelve or fourteen 
inches long, closed at one end, and its open extremity 
ground smooth, and having the bore not larger than 
the thumb can conveniently cover, holding from two 
to three cubic inches, each divided into tenths and 
hundredths by graduation on the glass, is tilled more 
than a third full of mercury, to which afterward a 
measured quantity of urine to be examined is poured, 
which may be from a quarter of a drachm to a drachm 
or upward, according to the capacity of the tube. 
Then, holding the tube in one hand, near its open ex- 
tremity, and having the thumb in readiness to cover 
the aperture, the operator fills it completely full with 
a solution of the hypochlorite of soda (taking care 
not to overflow the tube), and then instantly covers 
the opening tightly with the thumb, and having rapid- 
ly inverted the tube once or twice, to mix the urine 
with the hypochlorite, he finally opens the tube under 
a saturated solution of common salt and water, con- 
tained in a steady cup or mortar. The mercury 
then flows out, and the solution of salt takes its 
place, and the mixture of urine and hypochlorite 
being lighter than the solution of salt, will remain in 
the upper part of the tube, and will therefore be pre- 
vented from descending and mixing with the fluid in 
the cup. A rapid disengagement of minute bubbles 
of gas soon takes place in the mixture in the upper 



EXAMINATION OF THE URINE. 65 

part of the tube, and tlie gas is there retained and 
collected. The tube is then left in the upright posi- 
tion till there is no further appearance of minute glo- 
bules of gas being formed, the time being dependent 
upon the strength of the hypochlorite and the quan- 
tity of urea present. But the decomposition is usually 
completed in from three to four hours ; it may, how- 
ever, be left much longer, even for a day if convenient, 
and having set the experiment going, it requires no 
further attention ; and when the decomposition is 
completed, it is only necessary to read the quantity of 
gas produced off the scale on the tube. In cases 
where great accuracy is required, due attention must 
be paid to the temperature and atmospheric pressure, 
and certain corrections made if these should deviate 
from the usual standards of comparison, at the time 
of reading off the volume of gas ; but in most cases, 
sufficiently near approximation to accuracy may be 
obtained without reference to those particulars." 

It has been found by calculation that one cubic inch 
of gas corresponds to .64 of a grain of urea. There- 
fore, multiply the amount of gas by .64, and the pro- 
duct will be the amount of urea in the mixture. Ac- 
cording to the volume of urine employed, it is an easy 
matter to determine how much an ounce of the urine 
would contain, and from this, the total excretion of 
urea per day. 

There are one or two sources of error to be avoid- 
ed. Ammonia and uric acid will give rise to nitrogen 
gas, and thereby increase the apparent amount of urea. 
It is the ammonia which is most likely to exist in 
quantities sufficient to cause confusion, and we must 



GO 



EXAMINATION OF THE URINE. 



get rid of it by " gently heating the urine with a cer- 
tain quantity of baryta-water as long as the odor of 
ammonia is disengaged, and then filter the solution." 
The apparatus necessary to perform 
this analysis is shown in Fig. 18. The 
graduated tube can be procured of 
Benjamin & Co., No. 10 Barclay 
street. 

The hypochlorite of soda is pre- 
ferable to either that of lime or pot- 
ash, because it is easily procured, be- 
ing an article in general use under the 
name "Liquor Sodee Chlorinate," or Labarraque's 
Solution. But there are various preparations of this 
solution, both foreign and domestic, which do not 
correspond in strength, and are not universally kept 
on sale. Therefore, I used in my .experiments, a pre- 
paration of reliable manufacture, and the one most 
generally sold in the United States, namely, 
" Squibb's Liquor Sodae Chlorinate," and I advise 
its use in connection with this analysis. 




Fig. 18. 



PART VI. 

CALCULI AND GRAVEL. 

We have seen that the urine is' subject to a variety 
of deposits. Now, some of these are precipitated 
within the urinary passages under certain conditions, 
in a manner to form solid masses of considerable size. 

When the masses are small enough to be voided by 
the urethra, or pass from the kidney to the bladder, 
they are called gravel. During their passage, they fre- 
quently cause excessive pain, and by the irritation to 
the urethra or ureter, induce spasmodic contractions 
of those canals, and subsequent severe inflammation. 

It is important to be aware that the conditions 
which give rise to these small concretions are the 
same which favor the formation of larger ones, or 
calculi. 

Also gravel is in most cases the cause of larger con- 
cretions, as we will presently see. 

Calculi. — By a urinary calculus or stone, we mean 
those solid concretions found in the bladder and kid- 
ney, and which vary in size from that of a pea to a 
hen's egg. They differ in composition as well as in 
general form and texture. 

As regards composition, the most common are as 
follows : uric acid, oxalate of lime, urates^phospliatic^ 
and cystine. 



68 EXAMINATION OF THE URINE. 

There are several other extremely rare varieties, as 
ii r osteal it h, xanthine, and carbonate of lime. 

A stone is very rarely composed of one substance alone ; 
but is made up of alternating and varying concentric 
layers of different deposits. This happens as follows: 
A few crystals of uric acid, of oxalate of lime, or a 
mass of mucus, a clot of blood, or some foreign sub- 
stance accidentally introduced into the bladder, serves 
as a nucleus. Then the necessary conditions prevail- 
ing, we get a deposit of a layer, either of uric acid cr 
something else ; and thus the stone grows until finally 
its presence is irritating, and it begins to act as a foreign 
body ; and if it be removed at this stage, we shall 
have a pretty pure stone of uric acid, or whatever the 
predominating deposit up to this time has been. In- 
flammation follows, whereby the mucous membrane 
throws oif an extra quantity of mucus, which, min- 
gling with the urine, induces fermentation. As a 
result of this, the urea is decomposed, and carbonate 
of ammonia appears, to render the urine alkaline ; 
and then, of course, the earthy phosphates are preci- 
tated and add another layer to the stone. And so 
the very presence of the calculus conduces to its own 
growth. 

As before stated, w x e are not likely to have a stone 
made up of one material ; yet this may be the case, or, 
at any rate, one particular substance may predomi- 
nate and thereby impart its characters to a stone. 

Uric Acid. — Uric acid is the most common of all 
deposits going to form calculi. The nucleus of almost 
every stone is composed -of crystals of this substance, 



EXAMINATION OF THE URINE. 69 

and not unfrequently we see it constituting a stone 
almost entirely, especially if it be removed before the 
alkaline fermentation ensues. 

When this is the case, the size rarely exceeds that of 
a pigeon's egg. The color ranges from a brick-dust 
red to a fawn, and the surface is generally covered 
with little tubercles. If, however, there were more 
than one stone in the bladder, friction of their sur- 
faces would tend to make them smooth. 

They are usually spherical, and slightly flattened. 
When sawed in half, their concentric laminae are very 
distinctly seen. 

When a stone of this composition exists in the 
bladder, the urine is acid. 

Tests. — The murexid test is the most direct and 
characteristic. Place a fragment of the stone in a 
clean porcelain capsule, and add one or two drops of 
nitric acid ; now evaporate k the acid by gentle heat 
over the flame of a spirit-lamp, and a pink color will 
appear, which changes to a purple when a little am- 
monia is dropped in. 

Uric acid is soluble in an alkali. 

Under the blow-pipe, it is consumed, being of organ- 
ic origin, and a black ash remains. 

Urates. — Stones composed wholly of the urates are 
rare, though this deposit frequently alternates with 
others. 

When pure, they are small, and are apt to originate 
in the kidneys. Most frequently these calculi are 
met with in children. 



70 EXAMINATION OF THE URINE. 

The urine will have an acid reaction where these 
concretions exist. 

They are more or less of a red or brick-dust color. 

Tests. — The fact of their solubility in warm water 
will prove the presence of the urates. 

Oxalate of Lime. — Like other deposits, the oxalate 
of lime more frequently forms a stone by alternation, 
especially with uric acid. The nucleus may be uric 
acid or oxalate of lime. When the latter exists alone 
or predominates, the stone is exceedingly hard and 
rough ; in fact, it has been called the mulberry calcu- 
lus, from its warty and irregular surface. 

When the concretions of this formation are small 
enough to be classed as gravel, and arc voided with the 
urine, they may be smooth. Here, however, there is 
a mixture of the urates, and the formation has proba- 
bly taken place in the kidneys, and by their number 
the surfaces are worn. 

In color, these stones are sometimes dark brown or 
even black, and again almost white. 

Most mixed calculi contain layers of oxalate of 
lime. 

The urine will be strongly acid. 

Tests. — Oxalate of lime is soluble in the mineral 
acids. Under the blow-pipe, it is reduced to a dark 
ash, and when this ash is touched with moistened red 
litmus-paper, it turns it blue — caustic lime being the 
residue of the combustion. 

PHOSPHATES. 

AVe have seen that an alkaline condition of the 
urine would precipitate the earthy phosphates, and 



EXAMINATION OF THE URINE. 71 

that the alkalinity may be due to two causes, only 
one of which is concerned in the formation of phos- 
phatic calculi. We have said that the alkalinity of 
the fixed salts may continue for a length of time with- 
out a stone being found ; because the phosphatic pre- 
cipitate will then be amorphous, and has little ten- 
dency to form concretions. But when putrefaction 
occurs from retention of urine, or the action of in- 
flammatory products anywhere in the urinary pas- 
sages, then we have carbonate of ammonia developed, 
and now crystals of the ammonio-magnesian or triple 
phosphate are thrown down, as well as the amorphous 
phosphate of lime. 

It is the aramoniacal decomposition, then, which 
most influences the formation of phosphatic calculi. 

Sometimes, after prolonged administration of alka- 
line medicines, and as a result of high living where 
the urine is kept alkaline by the fixed salts, we have a 
jphosjj/iate of lime calculus formed. 

These stones are light colored, easily broken, and 
present an earthy fracture. They rarely alternate with 
other forms. 

Tests. — Phosphate of lime is insoluble in water ; 
soluble in a weak acid, and is practically infusible un- 
der the blow-pipe. 

Mixed or Triple Phosphates.— Deposits of this 
nature axe the result of the ammoniacal decomposition 
of urine, and consist of the crystalline ammonio-mag- 
nesian phosphate with the amorphous phosphate of 
lime. They rarely constitute the whole or interior of 
a stone, but are generally added as the result of the 



72 EXAMINATION OF THE URINE. 

presence of a pre-existing calculus, the irritation of 
which has induced the decomposition just mentioned. 
And it is a fact, that almost every stone, if it remains 
long enough in the bladder, will be encrusted with 
several layers of the mixed phosphates. 

So long as the ammoniacal decomposition continues, 
there will be no more layers of uric acid, urates, or of 
oxalate of lime; so that the interior of a stone may 
present a variety of deposits, while the crust is com- 
posed entirely of the phosphates. 

Accordingly, stones of this description sometimes 
attain to enormous dimensions. 

These calculi are chalk-colored, and have a glisten- 
ing appearance on account of the presence of the 
crystals of the triple phosphates on their surface. 

Tests. — Under the blow-pipe, the mixed phosphates 
readily fuse into a white enamel (and they have there- 
fore been sometimes called the fusible calculi), and 
give off ammonia and water. They are soluble in 
weak acids. 

Cystine. — This substance sometimes forms calculi 
and gravel. The number of cases is very limited, 
and very few specimens of the concretion exist. 
The stone is quite small, not larger than an almond, 
and of a dirty brown or greenish color. There appear 
to be no distinct laminee, but rather a radiating struc- 
ture. The pathology is obscure. 

Tests. — Cystine is soluble in the mineral acids ; in- 
soluble in water, organic acids, and carbonate of am- 
monia. Place a piece of the stone in contact with 
caustic ammonia, and allow the latter to evaporate, 
when the characteristic six-sided crystals of cystine 
will be visible under the microscope, 



SCHEME FOR EXAMINATION OF URINE. 

Proceed in the following manner : 

1. Odor. 

2. Color. 

3. Transparency. 

4. Reaction to test-paper. 

5. Specific gravity. 

6. Daily quantity. 

7. Any deposit. 

8. Apply reagents. 



Heat. 


PRECIPITATES. 


DISSOLVES. 


\ Albumen. 
j Phosphates. 


Urates. 


Nitric Acid. 


Albumen. 


Phosphates. 


Liq. Potassae. 


Phosphates. 





This table will be all that is necessary in the ma- 
jority of cases, and for the sake of simplicity, I omit 
the various complications, such as cystine, pus, bile, 
chyle, etc., for which see the text. 



SCHEME NO. 2. 

NORMAL. 

Urine, acid -f- heat gives no result. 

" alkaline -f- lie at gives earthy phosphates. 

" -f- nitric acid gives no result except darkening 

the color. 
u -f- potassa gives earthy phosphates. 
" -f- nitrate baryta gives alkaline sulphates. 
" -f~ nitrate silver gives chlorides. 

ABNORMAL. 

Urine (slightly acid) -\- heat gives albumen. 

" -f- n itric acid gives albumen. 
Other reactions same as normal urine. 
The other abnormal ingredients, blood, pus, cystine, 

spermatozoa, etc., are readily recognized under the 

microscope. 



GENERAL DIRECTIONS. 



Urine intended for examination should be placed in 
a conical-shaped glass vessel, such as an ordinary ale- 
glass, in order that any deposit which may appear 
shall be concentrated in a comparatively small space ; 
for if there is a very minute quantity, we otherwise 
might not be able to secure a specimen for the micro- 
scope. 

After the specimen has stood for six or eight hours, 
very gently pour off all but about half an ounce. 
This is done in order to prevent the deposited crys- 
tals, casts, or whatever is there, from becoming again 
mingled with a great quantity of urine when it is 
agitated by our subsequent manipulations. 

Now, having provided yourself with a drop-tube, 
which be sure is clean, place the finger over the large 
end, and direct the other end to the bottom of the 
glass ; raise the finger, and the urine ascends in the tube ; 
replace the finger, and we have it confined there. 
Touch the point of the tube thus supplied upon a 
clean glass slide, and a drop will escape, which is all- 
sufficient. A thin glass cover is placed over this drop 
on the slide in a manner to exclude air-bubbles, as 
follows : place one side of the cover on the slide and 
allow it to come gradually down. If the cover floats, 
there is too much urine, which will overflow^ it, and 
obscure the lens. Under such circumstances, just 
absorb the surplus urine with a little blotting-paper. 

We need a good J-inch lens for the examination of 
urinary deposits, and sometimes a -J-inch in order to 
distinctly discern small hyaline casts. 



LIST OF APPARATUS AND REAGENTS RE- 
QUIRED. 



Absolutely necessary. 



Special ap- 
paratus. 



APPARATUS. 

\ doz. 4-inch test-tubes. 
Test-tube rack. 
Alcohol lamp. 
Small glass funnel. 
Filter -paper to fit funnel. 
Red and blue litmus paper. 
$2.60. 

' Glass flask, 81. ) ^ ,., \. 

r* i . '. . f (Quantitative an- 

(Jubic centimetre or V ^ -, . r 

( alysis oi sugar, 
gram measure. ) J 

ni > . r -, , ) Quantitative an- 

GJass tube graduat- f -i • * 



ed to cubic inches. 



alysis of urea. 

$2. 



Nitric acid, 41. 
Acetic acid, 41. 
Sulphuric acid (pure), 41 . 
Solution caustic potassse (20 gr.-l ■ 
Sol. copper sulphate (1 3 -1 1 ), 4 1 , 
Sol. silver nitrate (10 gr.-l 1 ), 4 1 
Sol. barium nitrate (10 gr.-l 1), 4: 



$4. 



INDEX 



Acid, Effect of, upon Normal Urine 10 

Acid Fermentation 12 

Albumen 52 

Abnormal Urine 16 

Alkalies, Effect of, upon Normal Urine. . . . , 10 

Alkaline Fermentation 13 

B 

Baryta, Nitrate of, as Reagent 10 

Bile 58 

Blood 32 



Calculi, 67 

Cystine 72 

" Phosphates 70 

' ' Oxalate of Lime 70 

" Urates 69 

" Uric Acid 68 

Casts 35 

" Blood 40 

" Epithelium 39 

k ' Fatty 39 

' ' Granular 40 

■" Hyaline 38 

" Pus 41 

" Waxy 41 

Changes in Urine on standing 11 



78 INDEX. 

Chlorides \ 10 

Chylous Urine 44 

Color of Normal Urine 6 

Color of Abnormal Urine 16 

Cold, Effect of, upon Urine 9 

Composition of Urine 5 

Cystine . 47 

D 

Daily Quantity of Normal Urine 8 

" " " Abnormal Urine 19 

Deposits 21-51 

E 

Epithelium 29 

Bladder 29 

Renal 30 

Urethral 29 

Vaginal 29 

Extraneous Matters in Urine 36 

F 

Fehling's Solution, Composition of 60 

G 

Gravel , 67 

H 

Hematuria 33 

HcTematinuria 35 

Heat, Effect of, upon Normal Urine 9 

K 

Keistine 48 

L 

Lead, Subacetate of, as Reagent 10 



INDEX. 79 

M 

Moore's Test for Sugar 54 

Mould Fungus 49 

Mucus 30 

N 

Normal Urine, Characters of 5 

O 

Odor of Normal Urine 5 

1 ' " Abnormal Urine 16 

Oil in Urine 43 

Oxalate of Lime 11 

" " Calculus 70 

P 

Penicilium Glaucum 49 

Pigments 31 

Phosphates 12, 14, 25, 70 

Earthy 25 

Stella 25 

Calculi 70 

Pus * 42 

Q 

Quantitative Analysis 60 

of Sugar 60 

of Urea 63 

R 

Reaction of Normal Urine 6 

" " Abnormal Urine 17 

Reagents, Effects of, upon Normal Urine 9 

S 

Saccharomyces Cere visise 50 

Silver Nitrate, as Reagent 10 



80 INDEX. 

Specific Gravity of Normal Urine 7 

" " " Abnormal Urine 19 

Spermatozoa 4G 

Sugar, Tests for 54, 57 

" Quantitative Analysis of 60 

" Mould 50 

Sulphates, Alkaline •. 10 

T 

Transparency of Normal Urine 6 

" " Abnormal Urine 17 

Torula Cerevisia? 50 

Triple Phosphates 12, 26, 70 

Trommer's Test for Sugar 55 

U 

Urates. 23 

" Calculi 69 

Urea 11 

" Quantitative Analysis of. 63 

Uric Acid 11, 21,68 

" " Calculi 68 

Urinary Deposits 9 21 

V 

Vegetable Fungi 49 

Vibriones 51 



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